HAS-BLED

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HAS-BLED score
Purposerisk of major bleeding

HAS-BLED is a scoring system developed to assess 1-year risk of major bleeding in people taking anticoagulants for atrial fibrillation (AF). It was developed in 2010 with data from 3,978 people in the Euro Heart Survey. [1] Major bleeding is defined as being intracranial bleedings, hospitalization, hemoglobin decrease > 2 g/dL, and/or transfusion. [1]

Contents

Definition

HAS-BLED is a medical tool used to calculate the one-year risk of major bleeding for people on blood thinning drugs for atrial fibrillation (AF). [2] It is used with the CHA2DS2-VASc score. [3]

Use

ConditionPoints
 H   Hypertension: (uncontrolled, >160 mmHg systolic)
1
 A  Abnormal renal function: Dialysis, transplant, Cr >2.26 mg/dL or >200 µmol/L

Abnormal liver function: Cirrhosis or Bilirubin >2x Normal or AST/ALT/AP >3x Normal

1

1
 S  Stroke: Prior history of stroke
1
 B  Bleeding: Prior Major Bleeding or Predisposition to Bleeding
1
 L Labile INR: (Unstable/high INR), Time in Therapeutic Range < 60%
1
 E Elderly: Age > 65 years
1
 D Prior Alcohol or Drug Usage History (≥ 8 drinks/week)

Medication Usage Predisposing to Bleeding: (Antiplatelet agents, NSAIDs)

1

1

A calculated HAS-BLED score is between 0 and 9 and based on seven parameters with a weighted value of 0-2.

The HAS-BLED mnemonic stands for:

A study comparing HEMORR2HAGES, ATRIA and HAS-BLED showed superior performance of the HAS-BLED score compared to the other two. [4] Mixed evidence exist on the comparison between GARFIELD-AF bleeding score over the HAS-BLED. [5] [6]

2020 ESC guidelines on atrial fibrillation recommend assessment of bleeding risk in AF using the HAS-BLED bleeding risk schema as a simple, easy calculation, [7] whereby a score of ≥3 indicates "high risk" and some caution and regular review of the patient is needed. [8] The HAS-BLED score has also been validated in an anticoagulated trial cohort of 7329 people with AF - in this study, the HAS-BLED score offered some improvement in predictive capability for bleeding risk over previously published bleeding risk assessment schemas and was simpler to apply. [9] With the likely availability of new oral anticoagulants that avoid the limitations of warfarin (and may even be safer), more widespread use of oral anticoagulation therapy for stroke prevention in AF is likely.

While their use is recommended in clinical practice guidelines, [10] they are only moderately effective in predicting bleeding risk and don't perform well in predicting hemorrhagic stroke. [11] Bleeding risk may be increased in patients on haemodialysis. [12]

Score

A score of ≥3 indicates "high risk", but does not necessarily mean that an anticoagulant cannot be given, as some risk factors may be modified. [13]

Related Research Articles

A transient ischemic attack (TIA), commonly known as a mini-stroke, is a minor stroke whose noticeable symptoms usually end in less than an hour. TIA causes the same symptoms associated with strokes, such as weakness or numbness on one side of the body, sudden dimming or loss of vision, difficulty speaking or understanding language, slurred speech, or confusion.

<span class="mw-page-title-main">Anticoagulant</span> Class of drugs

Anticoagulants, commonly known as blood thinners, are chemical substances that prevent or reduce coagulation of blood, prolonging the clotting time. Some of them occur naturally in blood-eating animals such as leeches and mosquitoes, where they help keep the bite area unclotted long enough for the animal to obtain some blood. As a class of medications, anticoagulants are used in therapy for thrombotic disorders. Oral anticoagulants (OACs) are taken by many people in pill or tablet form, and various intravenous anticoagulant dosage forms are used in hospitals. Some anticoagulants are used in medical equipment, such as sample tubes, blood transfusion bags, heart–lung machines, and dialysis equipment. One of the first anticoagulants, warfarin, was initially approved as a rodenticide.

<span class="mw-page-title-main">Warfarin</span> Medication

Warfarin is an anticoagulant used as a medication under several brand names including Coumadin. While the drug is described as a "blood thinner", it does not reduce viscosity but rather inhibits coagulation. Accordingly, it is commonly used to prevent blood clots in the circulatory system such as deep vein thrombosis and pulmonary embolism, and to protect against stroke in people who have atrial fibrillation, valvular heart disease, or artificial heart valves. Less commonly, it is used following ST-segment elevation myocardial infarction and orthopedic surgery. It is usually taken by mouth, but may also be administered intravenously.

<span class="mw-page-title-main">Prothrombin time</span> Assay for evaluating the extrinsic pathway & common pathway of coagulation

The prothrombin time (PT) – along with its derived measures of prothrombin ratio (PR) and international normalized ratio (INR) – is an assay for evaluating the extrinsic pathway and common pathway of coagulation. This blood test is also called protime INR and PT/INR. They are used to determine the clotting tendency of blood, in such things as the measure of warfarin dosage, liver damage, and vitamin K status. PT measures the following coagulation factors: I (fibrinogen), II (prothrombin), V (proaccelerin), VII (proconvertin), and X.

<span class="mw-page-title-main">Ximelagatran</span> Anticoagulant

Ximelagatran is an anticoagulant that has been investigated extensively as a replacement for warfarin that would overcome the problematic dietary, drug interaction, and monitoring issues associated with warfarin therapy. In 2006, its manufacturer AstraZeneca announced that it would withdraw pending applications for marketing approval after reports of hepatotoxicity during trials, and discontinue its distribution in countries where the drug had been approved.

<span class="mw-page-title-main">Rivaroxaban</span> Anticoagulant drug

Rivaroxaban, sold under the brand name Xarelto among others, is an anticoagulant medication used to treat and prevent blood clots. Specifically it is used to treat deep vein thrombosis and pulmonary emboli and prevent blood clots in atrial fibrillation and following hip or knee surgery. It is taken by mouth.

<span class="mw-page-title-main">Dabigatran</span> Anticoagulant medication

Dabigatran, sold under the brand name Pradaxa among others, is an anticoagulant used to treat and prevent blood clots and to prevent stroke in people with atrial fibrillation. Specifically it is used to prevent blood clots following hip or knee replacement and in those with a history of prior clots. It is used as an alternative to warfarin and does not require monitoring by blood tests. In a meta analysis of 7 different studies, there was no benefit of dabigatran over warfarin in preventing ischemic stroke; however, dabigatran were associated with a lower hazard for intracranial bleeding compared with warfarin, but also had a higher risk of gastrointestinal bleeding relative to warfarin. It is taken by mouth.

The CHADS2 score and its updated version, the CHA2DS2-VASc score, are clinical prediction rules for estimating the risk of stroke in people with non-rheumatic atrial fibrillation (AF), a common and serious heart arrhythmia associated with thromboembolic stroke. Such a score is used to determine whether or not treatment is required with anticoagulation therapy or antiplatelet therapy, since AF can cause stasis of blood in the upper heart chambers, leading to the formation of a mural thrombus that can dislodge into the blood flow, reach the brain, cut off supply to the brain, and cause a stroke.

<span class="mw-page-title-main">Idraparinux</span> Chemical compound

Idraparinux sodium is an anticoagulant medication in development by Sanofi-Aventis.

Direct factor Xa inhibitors (xabans) are anticoagulants, used to both treat and prevent blood clots in veins, and prevent stroke and embolism in people with atrial fibrillation (AF).

<span class="mw-page-title-main">Vitamin K antagonist</span>

Vitamin K antagonists (VKA) are a group of substances that reduce blood clotting by reducing the action of vitamin K. The term "vitamin K antagonist" is technically a misnomer, as the drugs do not directly antagonize the action of vitamin K in the pharmacological sense, but rather the recycling of vitamin K. Vitamin K antagonists (VKAs) have been the mainstay of anticoagulation therapy for more than 50 years.

<span class="mw-page-title-main">Atrial fibrillation</span> Irregular beating of the atria of the heart

Atrial fibrillation is an abnormal heart rhythm (arrhythmia) characterized by rapid and irregular beating of the atrial chambers of the heart. It often begins as short periods of abnormal beating, which become longer or continuous over time. It may also start as other forms of arrhythmia such as atrial flutter that then transform into AF.

<span class="mw-page-title-main">Left atrial appendage occlusion</span> Medical treatment

Left atrial appendage occlusion (LAAO), also referred to as left atrial appendage closure (LAAC), is a procedure used to reduce the risk of blood clots from the left atrial appendage entering the bloodstream and causing a stroke in those with non-valvular atrial fibrillation.

The management of atrial fibrillation (AF) is focused on preventing temporary circulatory instability, stroke and other ischemic events. Control of heart rate and rhythm are principally used to achieve the former, while anticoagulation may be employed to decrease the risk of stroke. Within the context of stroke, the discipline may be referred to as stroke prevention in atrial fibrillation (SPAF). In emergencies, when circulatory collapse is imminent due to uncontrolled rapid heart rate, immediate cardioversion may be indicated.

Jonathan L. Halperin is an American cardiologist and the author of Bypass (ISBN 0-89586-509-2), among the most comprehensive works on the subject of coronary artery bypass surgery. In addition, he is the Robert and Harriet Heilbrunn Professor of Medicine at The Mount Sinai School of Medicine as well as Director of Clinical Cardiology in the Zena and Michael A. Wierner Cardiovascular Institute at The Mount Sinai Medical Center, both in New York City. Halperin was the principal cardiologist responsible for both the design and execution of the multi-center Stroke Prevention in Atrial Fibrillation (SPAF) clinical trials, funded by the National Institutes of Health, which helped develop antithrombotic strategies to prevent stroke, and he subsequently directed the SPORTIF clinical trials, which evaluated the first oral direct thrombin inhibitor for prevention of stroke in patients with atrial fibrillation.

<span class="mw-page-title-main">Apixaban</span> Anticoagulant medication

Apixaban, sold under the brand name Eliquis, is an anticoagulant medication used to treat and prevent blood clots and to prevent stroke in people with nonvalvular atrial fibrillation through directly inhibiting factor Xa. Specifically, it is used to prevent blood clots following hip or knee replacement and in those with a history of prior clots. It is used as an alternative to warfarin and does not require monitoring by blood tests or dietary restrictions. It is taken by mouth.

Direct thrombin inhibitors (DTIs) are a class of anticoagulant drugs that can be used to prevent and treat embolisms and blood clots caused by various diseases. They inhibit thrombin, a serine protease which affects the coagulation cascade in many ways. DTIs have undergone rapid development since the 90's. With technological advances in genetic engineering the production of recombinant hirudin was made possible which opened the door to this new group of drugs. Before the use of DTIs the therapy and prophylaxis for anticoagulation had stayed the same for over 50 years with the use of heparin derivatives and warfarin which have some well known disadvantages. DTIs are still under development, but the research focus has shifted towards factor Xa inhibitors, or even dual thrombin and fXa inhibitors that have a broader mechanism of action by both inhibiting factor IIa (thrombin) and Xa. A recent review of patents and literature on thrombin inhibitors has demonstrated that the development of allosteric and multi-mechanism inhibitors might lead the way to a safer anticoagulant.

The SAMe-TT2R2 score is a clinical prediction rule to predict the quality of vitamin K antagonist anticoagulation therapy as measured by time in therapeutic INR range (TTR) (VKA e.g. warfarin). It has been suggested that it can aid in the medical decision making between VKAs and new oral anticoagulant/non-VKA oral anticoagulant (NOAC e.g. dabigatran, rivaroxaban, apixaban or edoxaban) in patients with atrial fibrillation (AF). This score can be used with patients with ≥1 additional stroke risk factors using the CHA2DS2-VASc score, where oral anticoagulation is recommended or should be considered.

The European Heart Rhythm Association score of atrial fibrillation is a classification system for the extent of atrial fibrillation. It places patients in one of four categories based on how much they are limited during physical activity; the limitations/symptoms are in regard to normal breathing and varying degrees in shortness of breath and/or angina.

Gregory Lip is a clinical researcher and Price-Evans Chair of Cardiovascular Medicine, at the University of Liverpool. He is Director of the Liverpool Centre for Cardiovascular Science at the University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital.

References

  1. 1 2 Pisters, Ron; Lane, D. A.; Nieuwlaat, R; De Vos, C. B.; Crijns, H. J.; Lip, G. Y. (2010). "A Novel User-Friendly Score (HAS-BLED) to Assess 1-Year Risk of Major Bleeding in Patients with Atrial Fibrillation". Chest. 138 (5): 1093–100. doi:10.1378/chest.10-0134. PMID   20299623.
  2. ↑ "HAS-BLED Score for Major Bleeding Risk". MDCalc. Archived from the original on 25 February 2021. Retrieved 11 April 2021.
  3. ↑ Dan, Gheorhe-Andre; Steffel, Jan (2019). "4.1. Atrial fibrillation". In Kaski, Juan Carlos; Kjeldsen, Keld Per (eds.). The ESC Handbook on Cardiovascular Pharmacotherapy. Oxford: Oxford University Press. pp. 201–203. ISBN   978-0-19-875993-5.
  4. ↑ Apostolakis, Stavros; Lane, Deirdre A.; Guo, Yutao; Buller, Harry; Lip, Gregory Y. H. (28 August 2012). "Performance of the HEMORR(2)HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: the AMADEUS (evaluating the use of SR34006 compared to warfarin or acenocoumarol in patients with atrial fibrillation) study". Journal of the American College of Cardiology. 60 (9): 861–867. doi: 10.1016/j.jacc.2012.06.019 . ISSN   1558-3597. PMID   22858389.
  5. ↑ Fox, Keith A. A.; Lucas, Joseph E.; Pieper, Karen S.; Bassand, Jean-Pierre; Camm, A. John; Fitzmaurice, David A.; Goldhaber, Samuel Z.; Goto, Shinya; Haas, Sylvia; Hacke, Werner; Kayani, Gloria (21 December 2017). "Improved risk stratification of patients with atrial fibrillation: an integrated GARFIELD-AF tool for the prediction of mortality, stroke and bleed in patients with and without anticoagulation". BMJ Open. 7 (12): e017157. doi:10.1136/bmjopen-2017-017157. ISSN   2044-6055. PMC   5778339 . PMID   29273652.
  6. ↑ Proietti, Marco; Rivera-Caravaca, José Miguel; Esteve-Pastor, María Asunción; Romiti, Giulio Francesco; Marin, Francísco; Lip, Gregory Y. H. (18 September 2018). "Predicting Bleeding Events in Anticoagulated Patients With Atrial Fibrillation: A Comparison Between the HAS-BLED and GARFIELD-AF Bleeding Scores". Journal of the American Heart Association. 7 (18): e009766. doi:10.1161/JAHA.118.009766. ISSN   2047-9980. PMC   6222935 . PMID   30371183.
  7. ↑ Hindricks, Gerhard; Potpara, Tatjana; Dagres, Nikolaos; Arbelo, Elena; Bax, Jeroen J.; Blomström-Lundqvist, Carina; Boriani, Giuseppe; Castella, Manuel; Dan, Gheorghe-Andrei; Dilaveris, Polychronis E.; Fauchier, Laurent (2020-08-29). "2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS)". European Heart Journal. 42 (5): 373–498. doi: 10.1093/eurheartj/ehaa612 . hdl: 1887/3279676 . ISSN   1522-9645. PMID   32860505.
  8. ↑ Lip, Gregory Y.H. (2011). "Implications of the CHA2DS2-VASc and HAS-BLED Scores for Thromboprophylaxis in Atrial Fibrillation". The American Journal of Medicine. 124 (2): 111–4. doi:10.1016/j.amjmed.2010.05.007. PMID   20887966.
  9. ↑ Lip, Gregory Y.H.; Frison, Lars; Halperin, Jonathan L.; Lane, Deirdre A. (2011). "Comparative Validation of a Novel Risk Score for Predicting Bleeding Risk in Anticoagulated Patients with Atrial Fibrillation". Journal of the American College of Cardiology. 57 (2): 173–80. doi:10.1016/j.jacc.2010.09.024. PMID   21111555.
  10. ↑ Camm, A. J.; Lip, G. Y. H.; De Caterina, R.; Savelieva, I.; Atar, D.; Hohnloser, S. H.; Hindricks, G.; Kirchhof, P.; Bax, J. J.; Baumgartner, H.; Ceconi, C.; Dean, V.; Deaton, C.; Fagard, R.; Funck-Brentano, C.; Hasdai, D.; Hoes, A.; Kirchhof, P.; Knuuti, J.; Kolh, P.; McDonagh, T.; Moulin, C.; Popescu, B. A.; Reiner, Z.; Sechtem, U.; Sirnes, P. A.; Tendera, M.; Torbicki, A.; Vahanian, A.; et al. (2012). "2012 focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation". European Heart Journal. 33 (21): 2719–47. doi: 10.1093/eurheartj/ehs253 . PMID   22922413.
  11. ↑ Shoeb, Marwa; Fang, Margaret C. (2013). "Assessing bleeding risk in patients taking anticoagulants". Journal of Thrombosis and Thrombolysis. 35 (3): 312–9. doi:10.1007/s11239-013-0899-7. PMC   3888359 . PMID   23479259.
  12. ↑ Elliott, Meghan J.; Zimmerman, Deborah; Holden, Rachel M. (2007). "Warfarin Anticoagulation in Hemodialysis Patients: A Systematic Review of Bleeding Rates". American Journal of Kidney Diseases. 50 (3): 433–40. doi:10.1053/j.ajkd.2007.06.017. PMID   17720522.
  13. ↑ Kiser, Kathryn (2017). Oral Anticoagulation Therapy: Cases and Clinical Correlation. Springer. p. 20. ISBN   9783319546438.
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